Healthcare Provider Details

I. General information

NPI: 1568164424
Provider Name (Legal Business Name): SHANNON FERNANDEZ-LEDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 WASHINGTON ST STE 202
BROOKLINE MA
02446-4579
US

IV. Provider business mailing address

637 WASHINGTON ST STE 202
BROOKLINE MA
02446-4579
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-2811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1026483
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: